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Sanitation MDG is badly off track, but a community-led approach could fix that

Vast sums are wasted on programmes for free toilets, but the community-led total sanitation approach has helped millions avoid often fatal, faecally related infections.

Defecation mapping in progress in a village in the Democratic Republic of Congo, December 2010. This was set up by Tearfund and conducted by the CLTS team from Plan Kenya; 18 people attended this workshop, which 'triggered' action in six villages. Photograph: Philip Vincent Otieno/CLTS

Community-led total sanitation (CLTS) does not sound such a big deal, but it is revolutionary. We have so many “revolutions” in development that only last a year or two and then fade into history. But this one is different. In all the years I have worked in development this is as thrilling and transformative as anything I have been involved in. Let me explain.

Firstly, sanitation and scale: 2.6 billion people need improved sanitation and 1.1 billion defecate in the open. The millennium development goal (MDG) for sanitation is badly off track in most countries, which affects all the other MDGs.

Secondly, sanitation and hygiene matter much more than most people realise. Where they are lacking, the effects are horrendous. Faecally related infections are many. Everyone feels outrage because more than 2 million children are killed by diarrhoea each year. We hear about cholera outbreaks. But who hears about the guts of 1.5 billion people hosting greedy, parasitic, ascaris worms, about 740 million with hookworm voraciously devouring their blood, 200 million with debilitating schistosomiasis or up to 70 million with liver fluke? And what about dysentery, hepatitis, giardia, tapeworms, typhoid, polio, trachoma…?

A massive disease burden is associated with deficient hygiene, sanitation, and water supply and is largely preventable with proven, cost-effective interventions. The total benefits of these interventions are greater than the health benefits alone and can be valued at more than the costs of the interventions. Hygiene, sanitation, and water supply are development priorities, yet the ambition of international policy on drinking water and sanitation is inadequate. Hygiene, sanitation, and water supply continue to have health implications in the developed world. The active involvement of health professionals in hygiene, sanitation, and water supply is crucial to accelerating and consolidating progress for health.

A safe, reliable, affordable, and easily accessible water supply is essential for good health, but for several decades almost 1 billion people in developing countries have lacked access to such a supply. A poor water supply impacts health by causing acute infectious diarrhoea, repeat or chronic diarrhoea episodes, and nondiarrhoeal disease, which can arise from chemical species such as arsenic and fluoride. It can also affect health by limiting productivity and the maintenance of personal hygiene. Reasons for the limited progress towards universal access to an adequate water supply include high population growth rates in developing countries, insufficient rates of capital investment, difficulties in appropriately developing local water resources, and the ineffectiveness of institutions mandated to manage water supplies (in urban areas) or to support community management (in rural areas). Strenuous efforts must be made to improve access to safe and sustainable water supplies in developing countries, and, given the health burden on the public and the costs to the health system, health professionals should join with others in demanding accelerated progress towards global access to safe water.

2.6 billion people in the world lack adequate sanitation—the safe disposal of human excreta. Lack of sanitation contributes to about 10% of the global disease burden, causing mainly diarrhoeal diseases. In the past, government agencies have typically built sanitation infrastructure, but sanitation professionals are now concentrating on helping people to improve their own sanitation and to change their behaviour. Improved sanitation has significant impacts not only on health, but on social and economic development, particularly in developing countries. The health sector has a strong role to play in improving sanitation in developing countries through policy development and the implementation of sanitation programmes.

As the last article in a series on water and sanitation, this paper considers what needs to be done to make significant progress towards ensuring universal access to hygiene, sanitation, and water. We first discuss the differences between these three subsectors and the possible reasons for poor rates of progress towards achieving universal access in recent years. Then, we consider the actors whose engagement is essential for the sector, including the poor households themselves who are significant investors, local and central government, donors, and international agencies. Finally, we discuss the potentially important role of the health sector in improving hygiene, sanitation, and water worldwide and propose a detailed Agenda for Action.

This guidance document offers water supply and sanitation facility and hygiene promotion design considerations and recommendations intended to increase access to these facilities by people living with HIV. People living with HIV often require modifications to their water supply and sanitation facilities and hygiene practices due to their debilitating illness. This guidance document is intended for Home-Based Care (HBC) practitioners serving people living with this disease as well as water and sanitation engineers and technicians tasked with providing community water supply and household sanitation systems.

15 MARCH 2010 | GENEVA | NEW YORK — With 87% of the world’s population or approximately 5.9 billion people using safe drinking-water sources, the world is on track to meet or even exceed the drinking-water target of the Millennium Development Goals (MDGs), according to the new WHO/UNICEF Joint Monitoring Programme (JMP) report Progress on Sanitation and Drinking-Water –2010 Update Report, released today.

More needs to be done for sanitation

However, with almost 39% of the world’s population or over 2.6 billion people living without improved sanitation facilities, the report also points out that much more needs to be done to come close to the sanitation MDG target. If the current trend continues unchanged, the international community will miss the 2015 sanitation MDG by almost one billion people.

Improvements

The good news is that open defecation – the riskiest sanitation practice of all – is on the decline worldwide, with a global decrease from 25% in 1990 to 17% in 2008, representing a decrease of 168 million people practicing open defecation since 1990. However, this practice is still widely spread in Southern Asia, where an estimated 44% of the population defecate in the open.

Joint Monitoring Programme report

The JMP report presents the current status and trends in 209 countries or territories towards reaching the drinking-water and sanitation MDG target, along with an assessment as to what these trends reveal.

“We all recognize the vital importance of water and sanitation to human health and well-being and their role as an engine of development. The question now lies in how to accelerate progress towards achieving the MDG targets and most importantly how to leap a step further to ultimately achieve the vision of universal access”, said Dr Maria Neira, WHO’s Director for the Department of Public Health and Environment.

This report provides the clearest picture to date of the current use of improved sanitation facilities and improved sources of drinking-water throughout the world. The report is aimed to be used by policy-makers, donors, governmental and nongovernmental agencies to decide what needs to be done and where to focus their efforts to achieve these goals.

“We need to not only focus on reaching the water and sanitation MDG targets but also on achieving them with equity, ensuring that the most vulnerable groups and those hard to reach share in the successes achieved elsewhere,” said Dr Tessa Wardlaw, UNICEF’s Chief of Statistics and Monitoring.

Rural areas lagging

Despite the world’s population being almost equally divided between urban and rural dwellers, the vast majority without access to water and sanitation live in rural areas. Seven out of ten people without basic sanitation are rural inhabitants and more than eight out of ten people without access to improved drinking-water sources live in rural areas.

Disparity between rich and poor

A similar disparity is found between the poor and non-poor. A comparison between the richest and poorest 20% of the population in sub-Saharan Africa reveals that the richest are more than twice as likely to use an improved drinking-water source and almost five times more likely to use improved sanitation facilities. Although there is insufficient data at present, country data available confirms similar disparities elsewhere.

“With only five more years to go until 2015, a major leap in efforts and investments in sanitation is needed today in order to have an impact by the time we carry out our end-of-MDG evaluation,” said Robert Bos, Coordinator, Water, Sanitation, Hygiene and Health at WHO.

Unsafe water, sanitation and hygiene claim the lives of an estimated 1.5 million children under the age of five each year. Lack of access to water, sanitation and hygiene affects the health, security, livelihood and quality of life for children, impacting women and girls first and most. They are much more likely than men and boys to be the ones burdened with collecting drinking-water.

About the JMP

“With almost 884 million people living without access to safe drinking-water and approximately three times that number lacking basic sanitation we must act now as one global community to ensure water and sanitation for all,” said Ms Clarissa Brocklehurst, UNICEF Chief of the Water, Sanitation and Hygiene (WASH).

The WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation is the official UN mechanism tasked with monitoring progress towards MDG Target 7c on drinking water supply and sanitation. The report includes information from household surveys and censuses completed during the period 1985–2008. A record number of nearly 300 datasets were added to the global database for this year’s report. Importantly, the newer data have not yet registered the impact of the International Year of Sanitation (2008), which it is hoped will make a significant difference to the rate of progress towards the MDG sanitation target.

This book contains the principles a municipal government should consider before developing a citywide sanitation strategy. In this context, this strategy refers to a city’s strategic mid-term sanitation development plan, which incorporates vision, missions, objectives and targets as well as specifi c strategies to improve sanitation services.

Chapter 1 starts with an introduction of the background, objectives, concept, and the process of a city sanitation development, followed by a description of the position of the citywide sanitation strategy within the sanitation development planning process. The remaining chapters describe the steps to develop a citywide sanitation strategy. Chapters 2 to 6 explain the fi ve major steps of the process: a) establishing a working group, b) city sanitation mapping, c) defi ning a sanitation development framework, d) preparing a strategy for sanitation services development, and e) preparing a strategy for development of non-technical aspects. Chapter 7 concludes the book with a series of follow-up activities for implementation upon approval of the citywide sanitation strategy.

The book uses the phrase total sanitation services to mean the ideal level of sanitation services desired by a city. Such services should be accessible to all residents, be available city wide, be technically complete and sustainable, and not cause negative environmental impacts.

Many peri-urban communities use wastewater (often untreated) in agriculture. Although wastewater-dependent agriculture provides livelihoods to farmers, there are associated health and environmental risks. The roots of this situation lie in the poor sanitation in cities, both due to limited access to basic sanitation services and improper collection, treatment and discharge of wastewater into water bodies, which may subsequently be used for irrigation purposes. Addressing this situation requires integrated planning towards the improvement of conditions along the entire sanitation chain (from household latrines to collection, treatment and reuse of wastewater), while maintaining the characteristics of wastewater valued by farmers, such as nutrient content. This has been the basic premise behind the Wastewater Agriculture and Sanitation for Poverty Alleviation (WASPA) in Asia project, carried out in the towns of Rajshahi in Bangladesh and Kurunegala in Sri Lanka. This document provides an overview of the experiences of the project and provides a critical reflection on the WASPA concept and its applicability.

The project found that the sanitation situation in both cities was less severe than originally hypothesised. It was not only limited access to basic sanitation which contributed to wastewater flows; rather other more important sources of pollution were identified, such as discharges from small industries and leakage from poorly maintained or inadequate septic tanks. Yet, the situation also proved to be more complex than originally thought, necessitating that a broader range of stakeholders be involved in the identification and implementation of solutions. The multi-stakeholder approach of Learning Alliances and participatory planning cycle provided a useful framework for addressing this complex problem. This paper also identifies potential drawback to the approach, in that stakeholders tend to identify isolated and conventional actions to address the situation, and thus need strong facilitation and increased knowledge to arrive at appropriate solutions. Also, transaction costs of the approach are high, in terms of getting the teams in place, starting up the multi-stakeholder process, and getting stakeholders to carry out a joint planning exercise and subsequently implement their plans. However, the paper shows that integrated, joint planning is important for addressing complex problems that span sectoral, administrative and social divides and that, ultimately, the high transaction costs are justified.

Below is a current awareness bulletin of recently published reports and studies. If you would like to be on the Environmental Health at USAID mailing list for current awareness alerts, please send an email to: dcampbell@usaid.gov

USAID Hygiene ImprovementProject

Counseling Cards. Pictorially based tools prepared for home-based care workers to use with clients in the household, including a WASH Assessment Tool (to assess the current WASH behaviors to help identify those that need to be improved) and 23 Counseling Cards (covering hand washing; water treatment, storage and handling; feces management for mobile and bed-bound clients; and menstrual blood management).

Financing On-Site Sanitation for the Poor – A Six Country Comparative Review and Analysis, 2010. – Public investments of varying forms enable an absolute increase in the number of poor people gaining access to sanitation, varying from 20% to 70%, according to a study of six cases in Bangladesh, Ecuador, India, Mozambique, Sénégal, and Vietnam. This research seeks to identify the best-performing approaches and the relevant factors and issues to consider in designing a sanitation financing strategy. The report offers guidance to sector professionals developing on-site sanitation projects and programs, which play the leading role in providing access to sanitation

Information on improved latrine options – This booklet is really meant to be useful to anyone interested in and working on sanitation programs, and raise people’s awareness of options, create sanitation demand and work on actual construction of latrines.

Beyond tippy-taps: the role of enabling products in scaling up and sustaining handwashing – This article summarizes findings from the Water and Sanitation’s Global Scaling Up Handwashing Project and other research that suggest that convenient access to water and soap when and where needed and having a designated place for HWWS are also important determinant for handwashing. Enabling products such as handwashing stations provide such a designated place in addition to an environmental cue to action and a stable context for handwashing, factors that literature highlight as critical for habits to form and be maintained.